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Q. I was sent by email a couple of links from a colleague stating that Medicare covers MLD but not the bandaging, as it considers it an unskilled labor that can be taught to the patient. It states we can bill an education code (CPT® 97535) for up to 3 sessions to teach the patient how to bandage themselves. I have a private practice for the past 10 years and we provide 5 day a week CDT to our patients, and the bandaging is the work horse, in my opinion, in having a successful outcome. Over 40% of our clients are from Medicare. If this is true it will completely devastate our practice.

A. I have received similar questions over the last few years, and the issue is becoming very critical. Compression bandaging is a key part of complex decongestive therapy (CDT), as our questioner points out. My wife, Pearl, a 22-year breast cancer survivor and lymphedema patient, finds that simple decongestive therapy (self-MLD) followed by compression bandaging provides the most reliable treatment for her lymphedema.

Since the inclusion of manual lymph drainage (MLD) as a covered manual therapy modality under CPT® 97140, the usual policy was that compression bandaging was bundled with the MLD, with no separate billable code. Providers are bound by their Medicare contractor's Local Coverage Determination (LCD) for outpatient therapy if expected to be reimbursed by Medicare. Medicare Part B Contractors differ on how they interpret the issue. For example, in an August 20, 2014 update to billing instructions to their contractors, Noridian Healthcare Solutions, Jurisdiction E Part B Contractor, stated "the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare." [1]

Noridian goes on to state "However, a brief period, i.e. three or fewer sessions if no new specific issues are identified, of patient and/or caregiver education for home management of lymphedema with compression wrap applications may be medically necessary and reimbursable. Medical necessity for the education must be clearly indicated in the patient's record and must meet the code descriptor requirements for CPT® 97535, supporting home management training."[1] which confirms your information.

In 2010 a new code, CPT® 29581, was added to a group of Casting/Splinting/Strapping codes to provide Medicare coverage for strapping of a leg with multi-layer compression dressings as part of venous ulcer treatment. The venous compressions are performed for varicose veins, post-phlebitis syndrome, atherosclerosis, chromic venous hypertension, or stasis ulcers in the limb(s). Presence of a venous diagnosis (ICD-9 codes 459.11, 459.13, 459.31, 459.33, 707.10, 707.12 or 707.13) supports medical necessity. Lymphedema does not.

The addition in 2012 of CPT® codes to cover strapping of upper extremities as well as lower extremities was accompanied by exclusionary parenthetical notes precluding provision of these strapping services on the same day as manual therapy CPT® 97140. In a February 2012 AMA CPT® Editorial Panel Meeting the AMA Panel accepted the recommendations of the American Physical Therapy Association and American Academy of Physical Medicine and Rehabilitation, and deleted the CPT® 97140 exclusionary notes to the strapping codes to allow separate reporting of these services.[2] NCCI Edit changes to allow CPT® 29582-29584 to be billed together with CPT® 97140 were effective on April 1, 2012.

Note that the strapping/multilayer compression dressing codes CPT®s 29581-29584 are included within a set of musculoskeletal codes describing protocols for treatment of fractures, injuries, dislocations and other musculoskeletal diagnoses, that was later extended to treatment of venous wounds. They were never intended to be supported by soft tissue diagnoses such as lymphedema. Even though the exclusionary link with CPT® 97140 was removed, lymphedema was never added to the diagnoses supporting medical necessity of strapping.

A later interpretation may be found in the NCCI Edit Manual 2013, Chapter 2. Section F, Fractures, Dislocations, and Casting/Splinting/Strapping.

"F.15. Application of a multi-layer compression system (CPT codes 29581-29584) includes manual therapy in the anatomic region of the multi-layer compression system. CPT code 97140 (manual therapy techniques...) should not be reported for any type of manual therapy at the same patient encounter in the anatomic region where a multi-layer compression system is applied."[3] . [i.e. manual therapy is bundled with application of multilayer bandaging, and is not separately billable - RW]

Reference [1] clarifies this point for its providers: "Noridian will cover and separately reimburse the costs of the following procedures for non-lymphedema applications that meet Medicare coverage requirements:

Please see for a further history and explanation of the Medicare multilayer bandaging rules.

I originally reported this problem in the July 2012 issue of NLN LymphLink, and updated the information the following years on this web site. The information is still current for 2014. Medicare Contractor guidance issued in 2014 states "CPT code 97140 should not be reported for any type of manual therapy provided during the same patient encounter in the same anatomic region where a multilayer compression system is applied."[1].

I see no activity in the AMA CPT coding group agenda that would change this for 2015. The need remains for a lymphedema bandaging code to enable lymphedema-qualified therapists to bill for this essential component of CDT.

[1] High Compression Bandage System Clarification, Noridian Healthcare Solutions, Jurisdiction E, Part B Last Updated Aug 20, 2014.
[2] CPT® Editorial Panel Meeting, Summary of Panel Actions, Tab #20, February, 2012.
[3] Chapter IV, Surgery: Musculoskeletal System, CPT Codes 20000-29999 for National Correct Coding Initiative Policy, Manual For Medicare Services. CHAP4-CPTcodes20000-29999_final10312013.doc Revision Date: 1/1/2014

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